A major focus in outpatient anesthesia has become opioid-sparing techniques to minimize the patient’s exposure to addictive opioid medications. Along with increasing the frequency of peripheral nerve blocks for postoperative pain, we have become more creative with preoperative, intraoperative and postoperative medications that decrease the need for extensive opioid administration perioperatively. Ofirmev, an intravenous (IV) version of acetaminophen, is poised to be an effective part of an opioid-sparing cocktail, but is it worth the cost?
Revisiting Ofirmev as an Opioid-Sparing Strategy
Ofirmev has recently returned to the radar at The Orthopedic Surgery Center (OSC), the facility where I am the director of anesthesia services. When it first appeared on the market in 2011, the major concern in using it was cost. Most of our go-to anesthesia drugs such as ketamine, fentanyl, Toradol and Dilaudid cost less than one dollar per dose. Ofirmev, on the other hand, costs approximately ten dollars per dose. This price variance made it hard to seriously consider using it, especially with the rising cost of surgery for patients and decreasing insurance payments for providers and facilities. However, with the opioid crisis now making daily headlines, it was thought to be a good time to revisit Ofirmev as an adjunct to our opioid-sparing initiative.
Ofirmev’s Efficacy: Our Findings
The first question was to consider whether Ofirmev is effective as a part of an opioid-sparing anesthetic cocktail. We decided to use it initially on knee arthroscopy patients who did not receive nerve blocks for pain relief. We added Ofirmev as the first pain medication the patient would receive in the recovery room if there was a need. We would give Celebrex 200mg preoperatively followed by Toradol 30mg IV, decadron 4mg IV and fentanyl 100ug intraoperatively and save the Ofirmev for the first call for pain medications in the recovery room. The reason we gave the Ofirmev in PACU, upon request, was for psychological reasons. We noticed that giving it preoperatively did not decrease the amount of opioids given in PACU; however, giving it upon patient request in PACU had a better effect for the patient—just the act of seeing it being administered lessened the amount of opioids our average patients were getting by approximately fifty percent. The caveat here is that Ofirmev was significantly more effective on opioid-naïve patients. Patients that were on chronic pain medication not only required more opioids, but some even required a supplemental femoral nerve block for their pain to be tolerable. Unfortunately, this finding was not surprising.
Ofirmev’s Value: Worth the Cost?
Does the high cost of Ofirmev limit its use in a bundled payment scenario, such as in our surgery center? Ten years ago, the cost was absolutely the limiting factor in using it for a high percentage of our cases. Nowadays, even though the cost is the same, the landscape has changed with patients fearful of becoming addicted to opioids. Because of this concern, the real question becomes—is it worth using a medication that is more expensive for the purpose of potentially preventing an opioid habit that is prohibitively expensive, both financially and personally? I think, so far, the answer is “yes.”
The Bottom Line on Ofirmev
In patients having general anesthetics that do not require a peripheral nerve block, we found that Ofirmev administered in PACU upon first request for pain medication decreases their perioperative opioid requirements significantly. Is it better at pain relief than Toradol? My experience has been that it is not, but it is good as a supplement to a pre-existing regimen. In conclusion, for our facility, we have seen enough of a positive response to Ofirmev to continue its administration on select general anesthetic cases. It also has great value when the patient has a NSAID allergy or when the patient has a bad headache after anesthesia. Although it costs more than other medications in our arsenal, the benefits outweigh this negative aspect in light of the current opioid crisis.